There is no clear demarcation between those who have borderline personality disorder (BPD) and those who do not ; this is because the personality problems that contribute to a BPD diagnosis lie on a continuum. I have described the symptoms of BPD in numerous other articles that I have previously published on this site, but, for the sake of convenience, will list them again :

Three Criteria That Contribute To A Diagnosis Of BPD :

According to DSM V (The Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition) an individual must display at least five of these symptoms to be diagnosed as suffering from BPD.

However, as implied above, an individual does not either have these personality problems or doesn’t have them – things are not that clear cut or black and white. So how is it decided whether or not each symptom is serious enough to count towards a diagnosis of BPD?

Essentially, it is a question of three considerations. For each of the above nine key symptoms, it is necessary to ask :

Is the symptom chronic?

Does the symptom cause the sufferer, or other people, significant problems?

Does the symptom adversely affect multiple areas of the sufferer’s life?

Conclusion :

Essentially, the more of the above nine symptoms an individual has (as stated above, it is necessary to have a minimum of five to be diagnosed with BPD), and the more chronic, the more problematic and the more pervasive these symptoms are are, the more likely the individual is to be diagnosed with BPD ; so, BPD, like other personality disorders, lies on a continuum : deciding whether or not a person is suffering from it is not a clear cut decision.

However, diagnosis is not an exact science so there is always the possibility of unreliable diagnoses ; for example, person A may be diagnosed as having BPD by Dr X whereas person B may NOT be diagnosed as having BPD by the same doctor.

However, if both seek a second opinion from Dr Y, the diagnoses may be reversed (i.e person A is diagnosed as NOT having BPD whilst person B is diagnosed as having BPD. Of course, in the case of individuals suffering from particularly extreme (even within the context of the disorder) symptoms, diagnoses are likely to be more consistent and reliable.

More specifically, Buie and Adler hypothesize that, as a young child, the BPD sufferer was insufficiently ‘held’ by the mother, particularly during the rapproachment phase of interactions.

What Is Meant, In Psychotherapy, By ‘Holding’?

In psychotherapeutic terms, the word ‘holding’ does not necessarily entail literal, physical holding (although, ideally, of course, a mother would physically hold her young child when s/he was distressed and in need of comfort), but can also involve its emotional equivalent (verbally comforting and soothing the child, for example).

However, because of the mother’s failure to sufficiently ‘hold’ (physically, emotionally or both) the BPD sufferer when s/he was a young child in distress, s/he never had the opportunity to internalize adequate maternal ‘holding’ behavior so that now, as an adult, s/he lacks the ability to self-soothe in response to the further distress that s/he will inevitably experience as an adult.

Profound Feelings Of Aloneness :

Buie and Adler further propose that the BPD sufferer’s inability to ‘self-sooth’ at times of high stress leads to a pervasive and profound sense of aloneness ; indeed, Buie and Adler consider this deep sense of loneliness to be a core feature of the BPD sufferer’s psychological experience and describe it in the following manner :

‘an experience of isolation and emptiness occasionally turning into panic and desperation.’

Projection :

Also, according to Buie and Adler, BPD sufferers use the psychological defense mechanism ofprojection in relation to their profound feelings of inner isolation which means, in short, that they project these feelings onto the external environment, and, as a result of this, perceive the outside world, and life in general, to be empty, meaningless and devoid of purpose.

Longing To Be Held By Idealized Others :

Furthermore, Buie and Adler propose that this inability to self-soothe and self-nurture (due to the original failure to internalize maternal holding behavior, itself a result of the mother’s dysfunctional interaction with the BPD sufferer when s/he was a young child) leads to intense, desperate longing and desire to be ‘held’ by idealized others.

Separation Anxiety :

Additionally, according to Buie and Adler, such longings perpetually leave the BPD sufferer vulnerable to feelings of extreme separation anxiety.

Rage :

Because of the BPD sufferer’s proneness to idealize others (see above), Buie and Adler point out that this can lead to him/her (i.e. the BPD sufferer) to develop extremely exacting expectations of such idealized others that it is not possible for them (i.e. the idealized others) to live up to.

This inevitable failure of the idealized others to live up to the BPD sufferer’s stratospheric expectations can then induce feelings of extreme rage and anger in him/her (i.e. the BPD sufferer) directed at the ‘failed’, idealized other.

Implications For Therapy :

In line with their theory, Buie and Adler put forward the view that it is the role of the therapist to provide the holding and soothing functions that the BPD sufferer is not capable of providing for him/herself. The ultimate goal of this is that the BPD sufferer is eventually able to internalize these functions (holding and self-soothing) so that s/he learns to provide them for him/herself in a way that s/he was unable to as a child due to the defective nature of the mothering s/he received.

Peter Fonagy, an internationally renowned clinical psychologist, psychoanalyst and expert in borderline psychopathology and early attachment relationships, and who has produced some of the most influential work relating to this field, has stressed the importance of MENTALISING (or, more precisely, the avoidanceof it) in relation to borderline personality disorder (BPD).

What Is Meant By The Term ‘Mentalising’?

The term ‘mentalising’ refers to a person’s ability to perceive, understand and make use of other’s emotional states (and their own).

Why Might Those Suffering From BPD Avoid ‘Mentalising’?

According to Peter Fonagy’s theory, children of cold and rejecting parents avoid mentalising because thinking about their parents’ lack of emotional warmth, rejection, absence of love and, perhaps, even, hatred would be too psychologically distressing and painful.

Prevention Of Recovery :

However, Fonagy also theorizes that this evasion (both conscious and unconscious) of the truth about how one’s parents treated one and felt about one prevents the individual from resolving the trauma and recovering from theemotional mistreatment. He proposes that it is necessary for those suffering from borderline personality disorder (BPD) to confront, and consciously process, the traumatic elements of their childhoods, and, in particular, their difficult, perhaps tortured, childhood relationships with their parents.

The Need For Understanding And Verbal Expression :

Only by understanding what happened to one in childhood, and by learning to express, verbally, this understanding, Fonagy proposes, is recovery possible.

Conclusion :

Whilst Fonagy’s theory has been influential, some researchers have criticized it for not placing enough emphasis upon the fundamental problem sufferers of borderline personality disorder (BPD) frequently experience – namely their inability to control intense emotional reactions (often referred to as ’emotional dysregulation’ ; to read my previously published article relating to this, entitled ‘Three Types Of Emotional Control Difficulties Resulting From Childhood Trauma’, CLICK HERE. )

What Does ‘Diathesis’ Mean?

The medical definition of ‘diathesis’ is ‘a heriditary or constitutional predisposition to a disease or other disorder.‘ (The word ‘diathesis’ itself derives from the Greek word for ‘disposition).

What Is The Diathesis-Stress Model?

The diathesis-stress model is a psychological theory that proposes that a psychiatric disorder is caused not by heriditary factors (i.e. predispositional vulnerability)alone, NOR by psychologically stressful experiencesalone, but by the way in which the two factors interact with one another.

The diathesis-stress model is an appropriate model with which to explain how borderline personality disorder (BPD) develops in the individual. It is appropriate because research suggests that BPD does not occur in a person solely because of his/her traumatic and stressful childhood experiences nor solely because of an unfortunate genetic inheritance. What is vital in determining whether or not a person ‘succumbs’ to BPD is how their genes and childhood experiences combine and interact.

In other words, a person who is genetically vulnerable to developing BPD and experiences severe, protracted trauma during childhood may well go on to suffer from BPD in adulthood (see equation 1, below)

However, another individual who has low genetic vulnerability to the disorder and suffers a similarly traumatic childhood (although, of course, the ‘amount’ of trauma a person experiences is impossible to quantify – each case is utterly unique) may well avoid developing it (see equation 2, below)

So, we could represent the above with the following equations :

1) HIGH LEVEL OF CHILDHOOD TRAUMA + HIGH GENETIC VULNERABILITY = HIGH CHANCE OF DEVELOPING BPD.

More About Genetic Vulnerabilty To BPD :

In terms of genetic inheritance, what will make a person more susceptible to developing BPD?

The main consideration here is the person’s innate temperament. In particular, those who have naturally impulsive and emotionally labile personalities will, in general, be more predisposed to developing BPD if they also experience protracted and significant trauma during their childhoods compared to those more naturally inclined towards stoicism and timidity.

A Third Factor : Culture / Society :

However, the stress-diathesis model is not the whole story when we are considering the multiple, inter-relating causes that can lead to someone developing BPD. There is also the question of the culture / society in which the individual exists.

In terms of symptoms, there exists a clear overlap between the psychiatric conditions ofborderline personality disorder (BPD)and dissociative identity disorder (DID). DID used to be referred to multiple-personality disorder.

‘Splitting’ is a psychological defense mechanism in which one ‘part’ of the personality becomes separated / un-integrated with / isolated from another ‘part’ of the personality. In the case of individuals suffering from BPD, these two parts can, in simple terms, be described as PART ONE and PART TWO, where :

PART ONE represents the part of the person’s personality which is relatively accepting of him/herself and others

whereas :

PART TWO represents the part of the person’s personality which is full of self-hatred, as well as anger and hostility (and, underlying the latter two emotions, fear of being psychologically harmed) in relation to others.

When PART ONE is ‘operational’, it tends to enter a state of denial about the existence of PART TWO.

This may be because when PART ONE is ‘in charge’, the individual develops a state of mind similar to amnesia regarding the existence PART TWO ; alternatively, the denial may be underpinned by feelings of profound shame. However, more research needs to be conducted in relation to these possibilities.

‘Splitting’ and amnesia (when one part of the personality is unaware of how another part of the personality has manifested itself) are also symptoms of dissociative identity disorder.

As stated above, ‘PART ONE’ and ‘PART TWO’ have become un-intergratedin the personality of individuals suffering from BPD (the BPD sufferers personality, in this respect, may be described as having ‘disintegrated’). A more formal way to put this would be to describe the BPD sufferer as having an un-integrated ego-state (in contrast to the relatively integrated ego-state that psychologically ‘healthy’ individuals enjoy).

Those with BPD ‘switch’ between ‘PART ONE’ and ‘PART TWO’ and this can occur quite suddenly (but is not usually dramatically instantaneous).

Furthermore, these un-integrated ego-states interfere with each other (because they are notcompletely separate from one another) and this may cause symptoms such as the following :

How ‘Splitting’ Affects The BPD Sufferer’s Relationships With Others :

When ‘PART ONE’ is ‘in charge’, the BPD sufferer desires emotional attachments with others. However, when ‘PART TWO’ is dominant, s/he becomes hostile towards others and withdraws from them – this leads to the classic ‘love-hate’ scenario.

Why Does This Unintegrated Ego-State Arise In Those Suffering From BPD?

The two separate parts can develop in a person who has suffered severe and prolonged abuse as a child.

When the abused child becomes an adult, PART TWO (hostility etc) can be kept in abeyance for much of the time to allow daily social functioning. However, PART ONE makes itself apparent when the BPD sufferer is reminded of the abuse s/he suffered as a child (such a reminder is called a ‘trigger’).

This reminder/trigger may be detected by the BPD sufferer consciously or unconsciously and occurs as a defense mechanism against real or perceived psychological threat (especially the treat of betrayal, rejection or abandonmentas occurred in the individual’s childhood).

If the individual had not developed this defense mechanism as a child, s/he faced what may reasonably be termed as ‘psychological destruction.’ In other words, the development of the ‘splitting’ defense mechanism makes complete evolutionary sense as it allowed the individual to survive childhood – it is a normal, predictable, adaptive response to childhood loss, fear, distress and betrayal.

Conclusion ;

There is an overlap between symptoms of borderline personality disorder and dissociative identity disorder in as far as they both involve ‘splitting’ and ‘dissociating‘. However, in the case of DID, the separation between the different PARTS of personality are MORE DISTINCT AND CLEAR CUT THAN THEY ARE IN THE CASE BPD. Those suffering from DID may have more than two un-integrated / separate PARTS of their personality / ego-state ; however, arguably, this can also be the case in those suffering from BPD (although this is beyond the scope of this article).

In conclusion, though, we can say, with some confidence, that BPD sufferers do have a ‘split personality’, but the division between these two parts is more nebulous than in the case of DID sufferers.